11.scaling and root planing

SCALING AND ROOT PLANING

By

DR.PUNIT

FIRST YEAR PG29/02/2016monday

CONTENTS

• Introduction

• Historical background

• Definitions

• Changes in root surface in periodontitis

• Rationale of SRP

• Objectives

• Calculus Detection methods

• Instruments for SRP

– Hand instruments

• Principles of instrumentation

• Technique of SRP

– Sonic and ultrasonic instruments

– Rotating instruments

– Reciprocating instruments

– LASERS for SRP

• Post SRP evaluation

• Healing after SRP

• Scaling around implants

• Endoscopy aided SRP

• Polishing

• Conclusion

Non surgical

periodontal therapy

Mechanical non surgical

therapy

Pharmaco

therapeutics

Occlusaladjustments

Minor tooth movements

Plaque control

INTRODUCTION

• Non surgical therapy aims to eliminate both living bacteria in the microbial

biofilm and calcified biofilm microorganisms from the tooth surface and

adjacent soft tissues. A reduction in inflammation of the periodontium due

to lesser bacterial load leads to beneficial clinical changes.

• SRP (scaling and root planing) –considered to be the gold standard of periodontal therapy.

HISTORY

• Abu'l-Qasim (936-1013) was the preeminent physician and surgeon of the Western

Caliphate at Cordova. His contributions to dentistry and periodontology were

among his outstanding achievements.

• He had a clear understanding of the major etiologic role of calculus deposits and

described in detail the technique of scaling the teeth, using a sophisticated set of

instruments that he developed. He also wrote in detail on the extraction of teeth, the

splinting of loose teeth with gold wire, and the filing of gross occlusal

abnormalities

• Etiologic role of calculus deposits

• Described in detail the technique of scaling the teeth, using a sophisticated set of instruments

Abu’l- Qasim(936-1013)

• Father of modern dentistry

• The Surgeon Dentist,(1728)

• Described in detail his periodontal instruments and the scaling technique to "detach hard matter or tartar from the teeth."

Pierre Fauchard (1678 -1761)

18th century…..

The five types of instruments used by

Fauchard for detaching tartar from the

teeth:

1, chisel; 2, parrot beak; 3, graver; 4,

convex

blade; and 5, Z-shaped hook.

19th century……

• A Practical Guide to Operations on the Teeth.

• set of 6 scalers mostly spear shaped

1832-James Snell of London

• cofounder of Baltimore college of dental surgery

• The Dental Art

1839 – Chapin Harris

• Developed a set of 11 instruments for SRP.

1844- Paul Goddard, of Pennsylvania

• Designed a series of six instruments.

• Rigg’s original set of six instruments was the first to have various instrument designs for the different tooth surfaces to be treated.

John W Riggs (1811 - 1885 )

19th century……

• William J Younger (1838 – 1920 )• Follower of Riggs

• Made a real improvisation of Riggs instruments

• Curette styled with delicate blades and slender shanks but lack contra-angle.

• Robert Good• Student of Younger

• Modified Younger’s instruments.

20th century……

Younger Good instruments

• C M Carr • Major improvements in instrument design

• Contra-angling

• Two point contact on root surface

Carr’s partial set of Scalers

Entire set – 150 instruments with 144 hoes and 6 scalers.

• Younger Good set

• Mccall’s Set ( 8 planes, 3 sickles, 1 chisel, 18 curettes)

• Towner Periodontomes

• Austin James Planes ( concept of two point contact )

Till the mid twentienth century

• In 1930s CLAYTON H GRACEY of Michigan

• Offset blades

• Area specific

• Most popular till today.

SCALING

• Is the process by which plaque and calculus are removed from both supragingival and subgingival tooth surfaces .

(Carranza 10th edn)

• Is a procedure which aims at the removal of plaque and calculus from the tooth surface

(Lindhe 5th edition)

DEFINITIONS

Is the process by which residual embedded calculus and portions of cementum are removed from the roots to produce a smooth, hard and clean surface. (Carranza 10th edn)

A definitive treatment procedure designed to remove cementum or surface dentin that is rough, impregnated with calculus or contaminated with toxins or micro organisms. The definiton further states that “ when done in a thorough fashion, some unavoidable tissue removal occurs”

(1989 proceedings of world workshop)

Denotes a technique of instrumentation by which the ‘softened cementum’ is removed and the root surface is made “hard” and “smooth”. (Lindhe 5th edition)

ROOT PLANING

CHANGES IN ROOT SURFACE IN PERIODONTITIS

• Plaque and calculus deposition

• Alterations in exposed cementum

Structural changes

Chemical changes

Cytotoxicchanges

Structural changes• Light and TEM microscopy -Pathologic granules in exposed

root surface

• Represent areas of collagen degeneration or areas where collagen fibrils have not been fully mineralized initially.

A hypermineralized surface zone- most frequent

– Thickness – 10 to 20 μm

Changes in organic matrix:

– Loss of collagen cross banding at or near the cementumsurface.

Areas of demineralization:

– Proteolysis of the embedded remnants of sharpey’s fibres

– The cementum may be softened and undergo fragmentation and cavitation.

• Cytotoxic changes

– Exposed cementum becomes contaminated by bacterial endotoxins.

– Toxic to epithelium and fibroblasts.

Chemical changes– Mineral content of exposed cementum is increased.

• Calcium

• Magnesium

• Phosphorus

• Fluoride

• iron

Physical changes– Microhardness of cemental surface in relationship to the

periodontal pocket and immediately apical to the junctional epithelium is reduced when compared to a normal cemental surface that is covered by connective tissue

RATIONALE OF SCALING AND ROOT PLANING

Root Smoothness• Focal resorption lacunae - would serve as foci for reinfection

(Schroeder H E, 1983)

• Rough surface of calculus does not in itself induce

inflammation but the deleterious effect of calculus relates to

its ability to provide an ideal surface for microbial

colonization(Waerhaug 1952).

• . When the root surface is exposed to plaque and pocket

environment, its surface is contaminated by toxic substances,

notably endotoxins (LPS). When dentin is exposed plaque

bacteria may invade dentinal tubules, so scaling alone is

insufficient, portion of root surface must be removed to

eliminate them. (Hatfield et al, 1971; Aloe J 1974)

Removal of diseased cementum

• Contaminated by toxic substances, notably endotoxins (LPS).

• Hatfield & Baumhammers, 1971; first described the cytotoxiceffect of diseased root surfaces in tissue cultures

• Aloe J 1974 - observed that human gingival fibroblasts did not adhere to a root surface contaminated with LPS.

When dentin is exposed plaque bacteria may invade dentinal tubules, so scaling alone is

insufficient, portion of root surface must be removed to eliminate them.

• Nyman et al, (1986) – Biocompatible root surfaces are characterized by absence of

endotoxin or presence of minimal endotoxin levels compatible with health

– demonstrated in beagle dogs that the removal of diseased cementumwas not necessary for successful periodontal therapy

• Hughes et al, (1986 , 1988) - using an immunohistochemicaltechnique, showed that lipopolysaccharide was detectable on the cementum surface only.

• Moore et al.(1986) showed that 99% of the LPS associated with periodontally involved root surfaces could be removed simply by rinsing and brushing with tap water.

• Root debridement may therefore be defined as the removal of plaque and / or calculus from the root surface without the intentional removal of tooth structure. (Lindhe )

OBJECTIVES

• Suppression or elimination of the pathogenic periodontal microflora and replacement with the sparse flora found in health

• Conversion of inflammed, bleeding, or suppurative pathologic pockets to healthy gingival sulcus

• Shrinking of the deepened pathologic pocket to a shallow, healthy gingival sulcus

• Providing a root surface compatible with reestablishment of a healthy connective tissue and epithelial attachment.

DETECTION SKILLS

• Visual examination

• Tactile exploration

INSTRUMENTS FOR SCALING AND ROOT PLANING

• Hand instruments

• Sonic and ultrasonic instruments

• Reciprocating instruments

• Ablative laser therapy

Hand instruments

• Scalers

– Supragingival (sickles)

– Subgingival (hoes, chisels and files)

• Curettes

– Universal

– Area specific

• A hand instrument is composed of three parts: The working part (the blade), the

shank and the handle. The cutting edges of the blade are centered over the long axis

of the handle in order to give the instrument proper balance . The blade is often

made of carbon steel, stainless steel or tungsten carbide.

• Curettes are instruments used for both scaling and root planing. The working part of the curette is the spoon-shaped blade which has two curved cutting edges. The two edges are united by the rounded toe. The curettes are usually made "doubleended" with mirror-turned blades. The length and angulation of the shank as well as the dimensions of the blade differ between different brands of the instrument.

• Sickles

SUBGINGIVAL SCALERS

Chisel scalerUsed in interproximal area Used in a push motion

File Used to crush large pieces of calculus deposits.

Hoe Efficient in removing subgingival calculus Blade is beveled at 45 degreesWorking end is bent at an angle of 99 degrees to shank.

Curettes

Standard instruments of tray for mechanical debridement of teeth

PRINCIPLES OF INSTRUMENTATION

• Accessibility (Positioning of Patient and Operator)

• Visibility, Illumination, and Retraction

• Condition of Instruments (Sharpness)

• Maintaining a Clean Field

• Instrument Stabilization

• Instrument Activation

INSTRUMENT STABILIZATION

Instrument grasp

Fulcrums

Intraoral / Finger rests

Extra oral fulcrums

Instrument grasp

TRIPOD effectEnhances controlTactile sensitivity

FINGER REST

IMPORTANCE OF FINGER REST:

• Fundamental requirement for maintaining adaptation and optimal working angulation.

• Enables the operator to use wrist-arm motion to activate strokes.

• Maxillary right posterior sextant: facial aspect

• Operator position: Side position.

• Illumination: Direct.

• Visibility: Direct (indirect for distal surfaces of molars).

• Retraction: Mirror or index finger of the nonoperating hand.

• Finger rest. Extraoral, palm up. Backs of the middle and fourth fingers on

the lateral aspect of the mandible on the right side of the face.

• Maxillary right posterior sextant, premolar region only:

• facial aspect:

• Operator position: Side or back position.

• Illumination: Direct.

• Visibility: Direct.

• Retraction: Mirror or index finger of the nonoperating hand.

• Finger rest. Intraoral, palm up, Fourth finger on the occlusal surfaces of the adjacent

maxillary posterior teeth.

Maxillary right posterior sextant: lingual aspect:

Operator position: Side or front position.

Illumination: Direct and indirect.

Visibility: Direct or indirect.

Retraction: None.

Finger rest. Extraoral, palm up. Backs of the middle and

fourth fingers on the lateral aspect of the mandible on

the right side of the face.

Maxillary right posterior sextant: lingual aspect

Operator position: Front position.

Illumination: Direct.

Visibility: Direct.

Retraction: None.

Finger rest: Intraoral, palm up,

finger-on-finger. Index finger of the nonoperating hand on the occlusal

surfaces of the maxillary right posterior teeth; fourth finger of the operating

hand or the index finger of nonoperating hand.

Maxillary anterior sextant: facial aspect, surfaces away from the

operator

Operator position: Back position.

Illumination: Direct.

Visibility: Direct.

Retraction: Index finger of the nonoperating hand.

Finger rest. Intraoral, palm up. Fourth finger on the incisal edges or

occlusal surfaces of adjacent maxillary teeth.

.

• Maxillary anterior sextant: facial aspect, surfaces toward the operator

• Operator position: Front position.

• Illumination: Direct.

• Visibility: Direct.

• Retraction: Index finger of the nonoperating hand.

• Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the occlusal

or facial surfaces of adjacent maxillary teeth.

Maxillary anterior sextant: lingual aspect, surfaces away from the operator

(surfaces toward the operator are scaled from a front position)

Operator position: Back position.

Illumination: Indirect.

Visibility: Indirect.

Retraction: None.

Finger rest. Intraoral, palm up. Fourth finger on the incisal

edges or occlusal surfaces of adjacent maxillary teeth.

Maxillary left posterior sextant: facial aspect:

Operator position: Side or back position.

Illumination: Direct or indirect.

Visibility: Direct or indirect.

Retraction: Mirror.

Finger rest. Extraoral, palm down. Front surfaces of the

middle and fourth fingers on the lateral aspect of the

mandible on the left side of the face.

Maxillary left posterior sextant: facial aspect

Operator position: Back or side position.

Illumination: Direct or indirect.

Visibility: Direct or indirect.

Retraction: Mirror.

Finger rest. Intraoral, palm up. Fourth finger on the incisal edges or occlusal

surfaces of adjacent maxillary teeth.

Maxillary left posterior sextant: lingual aspect.

Operator position: Front position.

Illumination: Direct.

Visibility: Direct.

Retraction: None,

Finger rest: Intraoral, palm down, opposite arch, reinforced.

Fourth finger on the incisal edges of the

mandibular anterior teeth or the facial surfaces of the

mandibular premolars, reinforced with the index finger

of the non operating hand.

• Mandibular left posterior sextant: facial aspect

• Operator position: Side or back position.

• Illumination: Direct.

• Visibility: Direct or indirect.

• Retraction: Index finger or mirror of the nonoperating hand.

• Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the occlusal

or facial surfaces of adjacent mandibular teeth

Mandibular left posterior sextant: lingual aspect

Operator position: Front or side position.

Illumination: Direct and indirect.

Visibility: Direct.

Retraction: Mirror retracts tongue.

Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the

occlusal surfaces of adjacent mandibular teeth.

Mandibular left posterior sextant: lingual aspect

Operator position: Front or side position.

Illumination: Direct and indirect.

Visibility: Direct.

Retraction: Mirror retracts tongue.

Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the

occlusal surfaces of adjacent mandibular teeth.

Mandibular anterior sextant: facial aspect, surfaces toward the operatorOperator position: Front position.

Illumination: Direct.

Visibility: Direct.

Retraction: Index finger of the nonoperating hand.

Finger rest: Intraoral, palm down. Fourth finger on the

incisal edges or the occlusal surfaces of adjacent

mandibular teeth.

Mandibular anterior sextant: facial aspect, surfaces toward the operator

Operator position: Front position.

Illumination: Direct.

Visibility: Direct.

Retraction: Index finger of the nonoperating hand.

Finger rest: Intraoral, palm down. Fourth finger on the

incisal edges or the occlusal surfaces of adjacent

mandibular teeth.

Mandibular anterior sextant: facial aspect, surfaces away from the operator

Operator position: Back position.

Illumination: Direct.

Visibility: Direct.

Retraction: Index finger or thumb of the non operating

hand.

Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the

occlusal surfaces of adjacent mandibular teeth.

Mandibular anterior sextant: lingual aspect, surfaces away from the operator

Operator position: Back position.

Illumination: Direct and indirect.

Visibility: Direct and indirect.

Retraction: Mirror retracts tongue.

Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the occlusal

surfaces of adjacent mandibular teeth.

Mandibular anterior sextant: lingual aspect, surfaces

toward the operator

Operator position: Front position.

Illumination: Direct and indirect.

Visibility: Direct and indirect.

Retraction: Mirror retracts tongue.

Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the

occlusal surfaces of adjacent mandibular teeth

Mandibular right posterior sextant: facial aspect

Operator position: Side or front position.

Illumination: Direct.

Visibility: Direct.

Retraction: Mirror or index finger of the nonoperating

hand.

Finger rest. Intraoral, palm down. Fourth finger on the incisal edges or the

occlusal surfaces of adjacent mandibular teeth.

Mandibular right posterior sextant: lingual aspect

Operator position: Front position.

Illumination: Direct and indirect.

Visibility: Direct and indirect.

Retraction: Mirror retracts tongue.

Finger rest: Intraoral, palm down. Fourth finger on the incisal edges or the

occlusal surfaces of adjacent mandibular teeth.

INSTRUMENT ACTIVATION

• Adaptation

• Angulation

• Lateral pressure

• Strokes

ADAPTATION

• Adaptation refers to the manner in which the working end of a periodontal instrument is placed against the surface of a tooth.

• Objective of adaptation is to make the working end of the instrument conform to the contour of the tooth surface.

ANGULATION

• Angulation refers to the angle between the face of a bladed instrument and the tooth surface. It may also be called the tooth-blade relationship.

0 degree 45 – 90 <45 >90

STROKES

Direction

Length

pressure

Number

Gingival position and tone,

Pocket depth and shape,

Tooth contour

The amount and nature of the calculus

LATERAL PRESSURE

• Lateral pressure refers to the pressure created when force is applied against the surface of a tooth with the cutting edge of a bladed instrument.

• firm, moderate, or light.

• Insufficient lateral pressure

– burnished calculus that are difficult to detect and remove.

– often occurs in areas of developmental depressions and along the cementoenamel junction (CEJ).

TECHNIQUE OF SRP

• Supragingival scaling

– Supragingival calculus is generally less tenacious and less calcified than subgingival calculus.

– adaptation and angulation easier

– direct visibility as well as a freedom of movement

• Subgingival scaling and root planing

– Subgingival calculus is usually harder

– often locked into root irregularities

– Vision is obscured by the bleeding

– clinician must rely heavily on tactile sensitivity

– the adjacent pocket wall limits the direction and length of the strokes

– Varying root contours.

Subgingival scaling procedure.

A, Curette inserted with the face of the blade flush against the tooth.

B, Working angulation (45 to 90 degrees) is established at the base of the pocket.

C, Lateral pressure is applied, and the scaling stroke is activated in the coronal direction.

Initial pocket depth Mean reduction in PPD (mm)

Change in CAL (mm)

1-3 mm 0.03 -0.34

4-6mm 1.29 0.55

≥ 7 mm 2.16 1.19

• Evaluation of the response of the periodontium to scaling and root planing should be performed no earlier than 4 weeks following treatment (Caton et al. 1982, Kaldahl et al. 1988, Dahle´n et al. 1992).

• Measurements taken prematurely will not be representative of completed healing and could therefore be misinterpreted as a poor clinical response.

SONIC AND ULTRASONIC INSTRUMENTS

The removal of plaque and calculus is accomplished by

1. The vibration of the tip of the instrument.

2. The spraying and cavitationeffect of the fluid coolant.

Advantages and disadvantages of hand and ultrasonic instruments

ADVANTAGES DISADVANTAGES

Hand instruments

Superior tactile sensationGood access to tight pocketsGood adaptation to different root morphologiesNo aerosolsNo heat development

Angulation of the blade to root surface is mandatory.Frequent sharpening required.Considerable working force for calculus removalTiring for the operatorNegative time factor

Ultrasonic instruments

Current tips are very slenderInstrumentation virtually without pressureMost surfaces can be reached, especially furcationsDestruction of the biofilm by cavitationBactericidal effect of acoustic energyLittle soft tissue damagePocket irrigation with antimicrobial agentsRequires less timeNo sharpening requiredBetter patient acceptanceLess tiring to the operator

Poorer tactile sensationProduces microscopic rippling of the root surfaceAerosol is highly contaminatedPossible risk for patients with pacemakersContraindicated in patients with infectious diseases.

ROTATING INSTRUMENTS

• Fine grained diamonds

• Sonic scalers with diamond-coated inserts

• Carbide burs

ROTO-PRO BURS DESMOCLEAN BUR

•Root furrows, furcation areas can be easily instrumented.

Desmoclean®

• For curettage of the root surface in deep pockets, for bi-and/or trifurcation and in the approximal area

• For removal of tightly adhering granulations

• For removal of concrement (subgingival plaque)

• For periost ablation during flap surgery

•Non-cutting hexagonal head•Four shapes•Use with 7.000–10.000 rpm with light pressure and water spray

Reciprocating instruments

• Profin® Directional System

1.2mm

20000-30000 strokes/min

10 000-15 000 rpm

PROFIN :uses and applications:• Root Planing, scaling, and reshaping of existing restoration

margins, extensions and overhangs.• Reshaping restorations made of: amalgam, composite,

porcelain, precious and semi-precious metals.• Refining inter-dental gingival and incisal embrasures.• Contouring, spacing and individualizing anterior restorations.• Finishing shoulder margins and refining preparations.• Reshaping contacting tooth surfaces and minute incisal and

occlusal adjustments.• Fine-finishing porcelain or metal margins prior to

cementation.• Stripping, reshaping and polishing anterior and posterior

teeth with comfort and safety.

• PERIO-TOR® instruments

Mengel et al. (1994)- PER-IO-TOR" instruments have similar planingproperties as manual hand instruments, but cause minimal removal of tooth structures.

LASERs for SRP

Advantages

• Haemostatic effects

• Selective calculus ablation

• Bactericidal effects

(Aoki et al. 1994, 2004, Ando et al. 1996, Folwaczny et al. 2002)

Lasers most commonly used in periodontics• Semiconductor diode lasers

• Nd:YAG laser (neodymium doped: yttrium, aluminium, and garnet)

• Er:YAG laser (erbium doped:yttrium, aluminium, and garnet)

• Carbon dioxide (CO2) laser

Wavelength ranges from 635 to 10, 600 nm

Er:YAG laser

• wavelength of 2940 nm in the near-infrared spectrum (Ishikawa et al. 2004).

• High absorption of its emission wavelength by water-effectively remove calculus from periodontallydiseased root surfaces without causing thermal side effects to the adjacent tissue (Aoki et al. 1994, Eberhard et al. 2003, Schwarz et al. 2003)

Fluorescence- controlled (feedback system) Er:YAG laser

• Recently, 655 nm InGaAsP (indium gallium arsenide phosphate) diode laser radiation has been included in an Er:YAG laser device to induce fluorescence in subgingivalcalculus (Folwaczny et al. 2002b, Krause et al. 2003).

• Enabled an effective removal of subgingival calculus and a predictable root surface preservation in comparison with hand instruments (Schwarz et al. 2006, Krause et al. 2007).

RCTs comparing lasers and mechanical debridement in the treatment of chronic periodontitis

J Can Dent Assoc 2010;76:a30

Schwarz et al. 2008

SMEAR LAYER

• A smear layer is formed when dentin is cut or abraded.

• Close microscopic examination of the root surfaces after SRP reveals the resulting smear layer.

• organic matrix composed of cementum, dentin, and calculussmeared but not completely removed from the tooth surface.

POST SRP EVALUATION

• Immediately and after soft tissue healing.

• Immediately after instrumentation– Visual examination– Explorer / probe.

• Subgingival surfaces should be hard and smooth. • Although complete removal of calculus is definitely necessary

for the health of the adjacent soft tissue, Nevertheless, relative smoothness is still the best immediate clinical indications that calculus has been completely removed.

• The ultimate evaluation is based on tissue response.

• Clinical evaluation of the soft tissue response to scaling and root planing, including probing, should not be conducted earlier than 2 weeks postoperatively.

• Evaluation of the response of the periodontium to scaling and root planing should be performed no earlier than 4 weeks following treatment (Caton et al. 1982, Kaldahl et al. 1988,Dahle´n et al. 1992)

1-2 WEEKS AFTER ROOT PLANING:-

• Resolution of edema

• Shrinkage of gingival margin.

• Color is about normal.

• Moderate pocket depth may be present but there is little or no bleeding from the base of pocket when probed

• Histological epithelialisation is about completed

2 - 3 WEEKS AFTER ROOT PLANING:-

• Color is normal.

• Consistency is firm.

• No bleeding from base of pocket.

• Tooth mobility may decrease.

Histologically

• Immediate blood clot in pocket. Hemorrhage in tissues with dilated blood vessels and abundant neutrophils.

• Rapid proliferation of granulation tissue.

• Tissue maturation with decrease in number of small blood vessels.

Since periodontal disease is site specific (Goodson et al 1982, Hafajee 1983), each tooth or tooth surface should be evaluated for wound healing. If treated lesion still elicits bleeding nature of bleeding should be assessed.

HEALING AFTER SRP

Within few hours – an acute inflammatory reaction occurs inthe soft tissue pocket wall.

Within 2 days – remnants of pocket epithelium proliferate andthe pocket wall is fully epithelialized. Involution of pocketepithelium gives rise to junctional epithelium.

In 14 days – epithelial reattachment is complete and newgingival sulcus is formed near the crest of the gingiva. At thistime some gingival recession is apparent following reversal ofinflammatory swelling.

At 3-6 weeks – formation of functionally oriented collagentakes place to replace granulation tissue.

After 6 weeks – maturation of the CT component maycontinue for several months

• Restoration and re-epithelialization of sulcus in 2 to 7 days.

• Restoration of junctional epithelium within 5 days.

• Immature collagen fibres form within 21 days.

• Healing is mostly by long junctional epithelium with islands of connective tissue attachment

• connective tissue maturation continues for 21 to 28 days.

• Final gingival contouring may not be seen for 3-6 months.

SCALING AROUND IMPLANTS

• Do not scratch the titanium abutment.

• Instrumentation should be restricted to supragingival deposit removal.

• Strokes : short, controlled and activated with light pressure.

INSTRUMENTS FOR SCALING IMPLANTS

Material softer than titanium should be used.

• Plastic instruments

• Instruments with graphite fillers- for debriding crown or denture supported by the implant structure.

• Sonic and ultrasonic instruments with plastic sleeves over the metal tip.

PLASTIC INSTRUMENTS

Wrench shaped Crescent shapedHoe shaped

Plastic instruments similar to conventional curets and sickle scalers

ImplaKlean™ Implant

Scalers.

Hu friedy

• The power of the ultrasonic unit should be kept at a low setting.

• The point of the tip should never be placed directly on the implant, but rather the side of the tip is applied with light pressure.

• Overlapping horizontal, vertical, or oblique strokes should be used.

Endoscopy aided SRP

• Michaud et al (2007)

• No significant improvement in calculus removal compared to traditional SRP

POLISHING

• Polishing smoothed the tooth surface so that the causative agents of disease would be less likely to reaccumulate, and patient would be motivated to maintain smooth shiny tooth surface, the clinician created.

• coronal polishing is, at best , a cosmetic procedure with no health benefits and at worst, a procedure that damages the tooth surfaces.

But today, research literature has shown the following:Thorough brushing and flossing at home can produce the same effect as

polishingPolishing does not improve the uptake of fluorides.The use of an explorer and forceful rinsing are as effective as polishing

before sealant placement.Fluoride in the outer layers of enamel is removed by polishing, making the

tooth vulnerable to tooth decay.

In the past,It was important to have smooth, stain free surfaces to impede the

build up of new plaque.Stains and plaque must be removed before a fluoride treatment to

allow adequate uptake of fluoride in the enamel.It was necessary to polish tooth surfaces before sealent placement to

ensure proper acid etching and sealant penetration.

CONCLUSION

S/RP is an essential part of non-surgical periodontal therapy, yet does not result in complete removal of calculus .

Patient motivation and cooperation is important in successful treatment outcomes .

Re-evaluation provides a check for treatment success and patient’s level of cooperation

REFERENCES

• Carranza’s clinical periodontology – Newman ,Takei Klokkevold Carranza -tenth edition

• Clinical periodontology and implant dentistry- Jan lindhe Thorkild karringiklaus p. lang - fourth edition

• Periodontics in the tradition of gottileb and orban sixth edition Grant, stern

• Periodontal therapy clinical approach and evidence of success Myrennevins – vol I

• Periodontics medicine, surgery and implant by Rose and Mealey• Henry M Goldman and D. Walter Cohen – 1980 – Periodontol therapy 6th

edn.• Periodontology-The essentials, -Mueller• Cobb C M: Clinical significance of non-surgical periodontal therapy: an

evidence-based perspective of scaling and root planing. J Clin Periodontol2002; 29 (Suppl 2): 6–16.

• Drisko . Nonsurgical periodontal therapy Periodontology 2000, Vol. 25, 2001, 77–88

REFERENCES

• Fundamentals of periodontal instrumentation –Nield & Gehrig

• Cadosch J, Zimmermann U, Ruppert M, Guindy J, Case D, Zappa U. Root surface debridement and endotoxin removal. J Periodont Res 2003; 38; 229–236.

• Hu-friedy clinical application brochure. (available on http://www.hu-friedy.com)

• Michaud RM. The efficacy of subgingival calculus removal removal with endoscopy aided scaling and root planing. J Periodontol 2007;78:2238-45.

• Carranza . History of periodontology .

• Debora C. Matthews. Seeing the Light — The Truth about Soft Tissue Lasers and Nonsurgical Periodontal Therapy. J Can Dent Assoc 2010;76:a30

• Schwarz F, Aoki A, Becker J, Sculean A. Laser application in non-surgicalperiodontal therapy: a systematic review. J Clin Periodontol. 2008;35(8 Suppl):29-44.